Kalawar et.al. Comparative study of safety Health Renaissance 2015;13(2): 43-49
Original Article
Comparative study of safety and efficacy of electrocautery blade with cold scalpel blade for skin opening during fixation of fracture of forearm bone with plate and screws RP Shah Kalawar, GP Khanal, P Chaudhary, R Rijal, R Maharjan, SR Paneru, B Pokharel Department of Orthopaedics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
Abstract Background: Skin incisions have usually been made using a scalpel. Electrocautery, a more recent alternative, is thought to increase the risk of infection, impair healing and decrease cosmesis. Recent studies suggest that electrocautery may offer potential advantages with respect to blood loss, incision time and postoperative pain. Objective: The aim of this study was to compare the efficacy and safety of electrocautery incisions versus conventional scalpel incisions in orthopedic surgeries using internal implants. Method: The study was conducted as a prospective one in a tertiary care center in the Department of Orthopaedics, BPKIHS, Dharan, Nepal. Patients with closed fracture of the forearm bones admitted for surgery from April 2014 to September 2014 was included in the study. Each incision was divided into two halves, proximal half to be opened by steel scalpel blades and the distal half to be opened by an electrocautery blade. Proximal half and distal half of incision were compared on operating day and on days 2, 14 and again on 6 weeks and 3 month. Result: A total of 60 patients were enrolled in the study. Forearm skin incisions using electrocautery were significantly quicker than scalpel incisions (p0.05). Conclusion: There is no difference in healing of two halves of skin incision made by electrocautery and scalpel in orthopedic surgeries using internal implants. Key words: Electrocautery, skin incision, scalpel Introduction The
art
of
improved performing
surgeries
have
in
development
recent of
years
various
with
the
electrosurgical
devices assisting surgeons in performing Address for correspondence Rosan Shah Kalawar Department of Orthopaedics B.P. Koirala Institute of Health Sciences, Dharan Email:
[email protected]
safer surgeries with better outcomes. Skin incision has traditionally been made with a standard scalpel blade with good primary 43
Kalawar et.al. Comparative study of safety Health Renaissance 2015;13(2): 43-49
healing end results of the wound. The
•
Open fractures,
electrocautery has been used safely in
•
Previous history of hypertrophic or
performing
deeper
dissections.
Use
of
keloid scarring,
electrocautery in skin incision has been
•
Patients
suffering
from
discouraged in the past for the fear of
immunosuppressive
cutaneous scarring, wound dehiscence, and
wound healing problems,
infections particularly in orthopedic surgeries
•
chronic
disorders
or
Patients on long-term medications,
using internal implants.
which interferes with wound healing,
Recently, use of electrocautery has been
such as corticosteroids, anticancer
shown
drugs, or colchicines for gout.
to
offer
many
advantages
1-6
including time, safety and healing, yet still it is being debated. Therefore the present study
The patients were given numerical codes in
aimed
an
sequence. All surgeries were performed
electrocautery blade can be used safely for
under general/regional anesthesia with use of
skin incisions in limb surgeries.
tourniquets. The incision site was marked.
to
determine
whether
Each incision was then divided into two Methods
halves, proximal half to be opened by steel
The study was conducted as a prospective
scalpel blades and the distal half to be
one in a tertiary care center in the department
opened by an electrocautery blade [figure
of orthopaedics, BPKIHS, Dharan, Nepal.
1a]. The electrocautery unit was set on
Patients with closed fracture of the forearm
cutting pure mode, at a power of 5 W and
bones admitted for surgery from April 2014 to
using a 390-kHz sinusoid waveform during
September 2014 was included into the study.
the procedure.
The operating theatre records of 2013
The incision depth included the epidermis,
showed that the number of cases of forearm
dermis, and the superficial part of the
bones fracture operated from 1st April to 30th
subcutaneous layer. During electrocautery
September was 66. Arbitrarily it was decided
incision, only the tip of the blade was allowed
to take 60 of cases. Ethical clearance was
to come in contact with the proposed incision
obtained before the study from Institute
line and care was taken not to touch the skin
Ethical Review Board and informed consent
edges with the sides of the electrocautery
was taken from each patient involved in the
blade at any time by applying mild traction on
study. The following patients were excluded
either sides of the skin incision as the cutting
from study:
proceeded. 44
Kalawar et.al. Comparative study of safety Health Renaissance 2015;13(2): 43-49
The floor nurse noted the time taken to
On completing total skin incision, the wound
complete the incision on each side separately
edges were inspected for any physical
using a stop clock. The length of each half of
differences between the parts performed by
the incision was recorded. The speed of skin
the electrocautery and cold scalpel [Figure
incision was calculated in mm/s from the start
1b]. The incision wound with scalpel and
of incision until completion of the incision,
electrocautery was inspected in each case
including hemostasis. The speed of incision
immediately after completing the skin incision
was
in
with respect to color, viability, presence of
millimeters by time in seconds for each half
charring effect, and dermal peeling by naked
separately. The time calculated for incision
eye examination.
calculated
by
dividing
length
did not include deep fascia or periosteum opening.
Figure 1a: Skin incision marked and divided into proximal half to be opened by scalpel (S) and distal half to be opened by Electrocautery; 1b: Macroscopic appearance of the wound on completing skin Deeper dissection was continued as usual
after incision; cosmetic appearance of the
and fractures was fixed with a 3.5 mm low-
scar as good, poor, contracted; and formation
contact dynamic compression plate in each
of keloids and wound complications.
case. The wound was closed in layers using nylon or staples for the skin. The fascia was
Results
not closed to decrease the chance of
Sixty incisions were performed using a cold
compartment syndrome if any. The wound
scalpel and electrocautery blade in open
was inspected on postoperative days 2, 14
reduction and internal fixation of the fracture
and at 6-weeks post-operative follow-up. The
of the shaft of the radius and/or ulna using a
variables evaluated in this study was time
low-contact dynamic compression plate.
taken for incision; differences with respect to
The speed of incision when a cold scalpel
physical inspection of the wound edges soon
was used ranged between 0.65 mm/s and 2.1 45
Kalawar et.al. Comparative study of safety Health Renaissance 2015;13(2): 43-49
mm/s, with an average of 1.0 mm/s. The
cold scalpel and electrocautery incisions.
speed of incision with electrocautery blade
Postoperative inspection on days 2 and 14
was between 1.2 mm/s and 2.9 mm/s, with an
also did not have any differences in the
average of 1.8 mm/s. The average time taken
physical character of the wound [Figure 2a].
by electrocautery for performing a 10 cm skin
Healing of skin wound incised with cold
incision was 1 min against 2 min by cold
scalpel and electrocautery at the end of 6
scalpel.
The time taken for incision with
weeks and 3 months were the same [Figure
electrocautery was much lower in comparison
2b]. There were no differences in scar
with the cold scalpel.
tenderness on either half of the incision made
There were no macroscopic differences with
by cold scalpel and electrocautery at 3
respect
months follow up.
to
color,
viability,
presence
of
charring effect, and dermal peeling between
Figure 2a: Macroscopic appearance of the wound on 2nd week follow up and 2b: on 6 month follow up.
Because of the tourniquet application, blood
or electrocautery incision in 3 month follow
loss with these two methods of incision could
up.
not be evaluated. Two
(3.3%)
cases
of
superficial
Discussion
stitch
abscess were found involving the full length
Surgical electrocautery has increasingly been
of the skin incision, which was effectively
used for tissue dissection, being haemostatic
managed
and convenient, since beginning of the 20th
with
antibiotics
and
regular
dressings.
century when it was first introduced7-9.
There was no evidence of scar tenderness,
Surgeons, however, continue to be reluctant
hypertrophy, or keloid formation of the scar,
when it comes to the use of electrocautery for
or wound dehiscence either with cold scalpel
making an incision of skin9,10,11 because 46
Kalawar et.al. Comparative study of safety Health Renaissance 2015;13(2): 43-49
previous studies has shown that the use of
fixation of the fracture of the shaft of the
electrocautery causes devitalization of tissue
radius and/or ulna using a low-contact
within the wound which consequently lead to
dynamic compression plate. Blood loss could
wound infection, delayed wound healing and
not be compared due to use of tourniquet.
excessive
scarring
9,10,12,13
.
Despite
The
this
fear
of
tissue
injury
and
wound
evidence in these randomized clinical trials in
complication in electrocautery incision was
support of electrocautery use in making skin
first unfolded when this technique was used
incisions, many surgeons in many centers
by Peterson16 in reconstructive and cosmetic
including our centre still are reluctant to use
faciomaxillary
electrocautery in making skin incisions
10,11
.
Tobin17
surgery,
in
blepheroplasty, with minimum scarring and
So this study was aimed at investigating this
excellent results.
alternative
with
Kearns et al12 who compared electrosurgical
comparison to the scalpel incision with
and scalpel methods in hundred patients
regards
undergoing elective midline incision have
to
method
of
advantages,
incision like
time
and
bleeding, as well as alleged complication like
found
wound infection.
significant advantages over scalpel incision
There are conflicting results
that
the
diathermy
incision
has
based on incision time, blood loss, early
in human
studies. It has been reported in Soballe et al14
postoperative
pain
study that electric coagulation increases the
requirements.
There
incidence of indurated margins, infections,
difference in terms of wound complications,
and
including wound infection, as reported by the
weakness
of
the
wound
cut
in
comparison with the knife. Conversely, Groot et
al15
reported
that
use
of
and was
no
analgesia significant
present study.
surgical
The present study showed no statistically
electrocautery to create surgical wounds in
significant
patients undergoing abdominal or thoracic
postoperative
operations carries a wound infection rate
postoperative hospital stay which is in
similar to that of scalpel.
consistent with other trials9,12. On the basis of
Our present study shows electrocautery
this study, it is suggested that skin may be
incision is better than scalpel incision in terms
safely incised using electrocautery in limb
of time taken for incision, and no significant
surgery involving fixation of bones using
difference in terms of wound healing, post
internal implants.
operative complication rate and in length of hospital stay in open reduction and internal 47
differences
in
the
complications
rate
of and
Kalawar et.al. Comparative study of safety Health Renaissance 2015;13(2): 43-49
Conclusion
blind, randomized, clinical trial. World J
We conclude that skin may be safely and
Surg 2009; 33:1594-9. 6.
rapidly incised using electrocautery in limb
Chalya PL, Mchembe MD, Mabula JB,
surgery involving fixation of bones using
Gilyoma JM. Diathermy versus Scalpel
internal implants with as good wound healing
incision in elective midline laparotomy:
characteristics as that of with cold scalpel.
A prospective randomized controlled clinical
study.
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